Cardiovascular and Peripheral Vascular Assessment


Overview of Assessment Goals

  • The focus is on conducting a comprehensive cardiovascular and peripheral vascular assessment in one session.

  • Ensure both arms are used for blood pressure measurement to allow for comparison.

Vital Signs Measurement

  • Blood pressure must be taken in both arms in today's assessment.

  • After today, only one arm will be measured for blood pressure moving forward.

  • Emphasize practice and proficiency in measuring blood pressure.

Cardiovascular Assessment Steps

1. Inspection

  • Initial Steps:

    • Start with visual inspection of the patient's chest.

    • Assess skin appearance, particularly over the cardiac region.

    • Look specifically for any movements, such as lifts or heaves, coinciding with the patient's breathing.

  • Key Points to Inspect:

    • Observe for lifts and heaves mainly along the base of the heart, and at the right and left sternal borders.

    • Not mentioned: "No lifts or heaves noted."

    • Positioning for apical impulse assessment:

    • Locate the fifth intercostal space at the left midclavicular line.

    • Only 25% of the population will have a visible point of maximum impulse.

  • Ensure symmetry of chest wall, and check for any masses, lumps, redness, tenderness, or abnormalities.

2. Palpation

  • Primary Areas of Focus:

    • Carotid artery and apical impulse—these should be assessed for synchrony.

    • Compare the apical impulse with the carotid pulse to ensure they match.

  • Size of Apical Impulse:

    • Typical size is about that of a quarter.

  • Check for Lifts and Heaves:

    • Use palmar side of hand to palpate apex, left sternal border, and base of the heart.

    • Record findings—"no lifts or heaves noted" would be typical.

  • If any abnormalities are noted, auscultation should be performed immediately after with a stethoscope to further evaluate these findings.

3. Auscultation

  • Techniques and Equipment:

    • Use both sides of the stethoscope (bell for lower sounds, diaphragm for higher sounds).

    • Conduct auscultation in three different positions: sitting upright, supine, and left lateral decubitus.

  • Five Auscultation Points:

    • 1) Aortic area: Second intercostal space, right sternal border.

    • 2) Pulmonic area: Second intercostal space, left sternal border.

    • 3) Erb's point: Third intercostal space, left sternal border.

    • 4) Tricuspid area: Fourth intercostal space, left sternal border.

    • 5) Mitral area: Fifth intercostal space, left midclavicular line.

  • Sounds to Listen For:

    • S1 (first heart sound) and S2 (second heart sound) are expected sounds during auscultation with the diaphragm.

    • S3 (third heart sound) and S4 (fourth heart sound) are lower sounds which should be noted using the bell.

  • Documentation:

    • Accurately document findings from each position and site.

    • Include observations such as:

    • "S1 is quieter than S2."

    • Document the presence of S3 or S4 as necessary.

    • Mention if there is a split S2 during inspiration.

  • Charting Recommendations:

    • Some students use diagrams to log information on findings at specific positions.

    • Write exactly what is heard instead of what is expected or assumed.

Vital Signs Documentation

  • Conduct a full set of vital signs excluding temperature.

  • Blood pressure for both arms should be recorded and compared; significant differences may indicate underlying issues.

  • Manual measurements are required for heart rate, respiration, and blood pressure, with the exception of pulse oximetry which may use a machine.

  • Proper technique requires counting respiration, not just acknowledging them visually.

Equipment and Resources

  • Abnormal Heart Sounds Machine:

    • Accessible for reviewing sounds like S3 and S4, clicks, or snaps to assist in understanding auscultatory findings.

Clinical Practicalities and Notes

  • If blood pressure measurement reveals substantial discrepancies, repeat the measurements and report findings for further evaluation.

  • Emphasize accuracy and what is actually heard during auscultation rather than relying on expectations.

Closing Remarks

  • Review and understand vital sign measurement protocols extensively as part of the clinical training.

  • Engage with peers for practice in auscultation and blood pressure measurement to reinforce skills.

  • Prepare to dive deeper into implications of peripheral vascular disease in the upcoming lecture.

Questions and Clarifications

  • Clarification on blood pressure protocol: Blood pressure should be measured on both arms on the same day, allowing for accurate clinical comparison.